NYC03FA080

NTSB accident investigation · Dassault DA-20 · Swanton, OH · April 8, 2003

Accident · FatalField investigationFinal report
Date
April 8, 2003, 13:49 local (17:49 UTC)
Place
Swanton, OH
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N183GADassault DA-20
Weather
Instrument (IMC) · Day
Status
Completed · report June 2, 2004
Report
Approved by Office Director
Parties
Grand Aire Express, Dassault Falcon Jet, Federal Aviation Administration, General Electric
FAA report
20030408019819A
Case key
56766

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The flight instructor's inadequate supervision of the flight, including his failure to maintain an approach airspeed consistent with the airplane's configuration, which resulted in an aerodynamic stall due to slow airspeed, and subsequent uncontrolled descent into trees. Factors were the icing conditions, the flight instructors failure to turn on the wing and engine anti-ice, and his lack of experience as an instructor pilot in the airplane.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherApproach
Anti-ice/deice system - improperPilot in command(cfi)Factor
Weather condition - icing conditionsFactor
Loss of control - in flightApproach - faf/outer marker to threshold (ifr)
Supervision - inadequatePilot in command(cfi)Cause
Lack of total experience in type operationPilot in command(cfi)Factor
Airspeed - not maintainedPilot in command(cfi)Cause
Stall/mush - inadvertentPilot in command(cfi)
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

The flight crew of the Fan Jet Falcon (DA-20) were practicing ILS approaches in instrument meteorological conditions with low clouds and rime ice. A first officer (FO) in training occupied the right seat, while the pilot-in-command (PIC), who was also the company chief pilot/check airman/designated flight instructor, occupied the left seat and was handling the radios. On the second approach, the airplane struck trees and burned, 1.57 nm from approach end of the runway. The landing gear was found extended, and the trailing edge and droop leading edge flaps were retracted. The wing and engine cowl anti-ice valves were found closed, consistent with it being off in the cockpit. Radar data revealed that on approach, the airspeed decreased from 188 knots to 141 knots at the outer marker, and continued to decrease down to 106 knots, when the airplane entered an abrupt descent and disappeared from radar. Simulator flights matched the radar profile with a flight idle approach, a power reduction inside the outer marker, and 1/4 inch of ice on the wings. In the simulator, the airplane stalled about 2 miles from the end of the runway with an airspeed of 103 kts. At flight idle, the engine power in the last 2 minutes of approach was below the recommended power setting for wing or engine anti-ice to be effective. Vref and stall speeds were computed to be 129 kts and 96 kts, with wing flaps and droop leading edges retracted. The PIC had about 1,100 hours in the make and model. The PIC did not have any documented previous flight instruction experience in make and model or any other multi-engine airplanes. The PIC had given 4 pilot proficiency checks in the DA-20 since receiving his check airman designation. The company Director of Operations reported that the accident FO was the first student the PIC had taken through the initial second-in-command course. The PIC and FO had received all of their turbojet experience with the operator.

Factual narrative

History of flight

On April 8, 2003, at 1349 eastern daylight time, a Dassault Fan Jet Falcon (DA-20), N183GA, operated by Grand Aire Express Inc. (GAE), as flight 183, was destroyed when it struck trees while on an instrument approach to Toledo Express Airport (TOL), Swanton, Ohio. The two certificated airline transport pilots, and pilot rated passenger were fatally injured. Instrument meteorological conditions prevailed for the instructional flight, which last departed from Cherry Capital Airport (TVC), Traverse City, Michigan. The flight was conducted on an instrument flight rules (IFR) flight plan under 14 CFR Part 91.

According to the Director of Operations (DO) for Grand Aire Express, the flight was dispatched from Toledo with a 14 CFR Part 135 qualified flight crew on board, and a first officer in training (FO), who occupied the jump seat with no required duties.

According to records from the Federal Aviation Administration (FAA), prior to departure from Toledo, the direct user access terminal system (DUATS) was accessed using a Grand Aire logon. Selected notices to airmen (NOTAMS), terminal forecasts (TAFs), and aviation routine weather reports (METARS) were requested by the logon user.

The airplane then flew from TOL to Grand Rapids (GRR), Michigan, where cargo was loaded. There was no servicing while the airplane was on the ground at Grand Rapids. However, flight service was contacted by the flight crew and an IFR flight plan was filed to Traverse City. The latest weather for Traverse City, and their alternate airport was also requested. When asked if any additional weather was needed, the offer was declined.

There were no reported problems on the flight between Grand Rapids and Traverse City. While on the ground at Traverse City, the airplane was serviced with 150 gallons of Jet-A aviation grade turbine fuel.

Flight service was again contacted by the flightcrew and an IFR flight plan to Toledo was filed. No weather information was requested.

The return flight to Toledo was planned as an instructional flight for the FO, who was being prepared for his 14 CFR 135, second-in-command checkride. The pilot-in-command (PIC) occupied the left seat. He was the company chief pilot, an FAA designated check airman, and a company designated flight instructor. The FO in training occupied the right seat, and the 14 CFR Part 135, DA-20 qualified first officer occupied the jump seat, as a pilot rated passenger with no required duties.

There were no reported problems with the departure or en route phases of the flight. The pilots initially contacted Toledo Approach Control at 1324.

The pilots initiated a practice ILS approach to runway 07, with the intent to perform a missed approach. During the missed approach, the airplane was radar vectored for a second ILS approach to runway 07.

The air/ground communications tape between the airplane and approach control was reviewed. The director of operations identified the voice that was responding to radio calls as the PIC.

According to an FAA transcript of air/ground communications, at 1345:29, Grand Aire flight 183 was requested to maintain 180 knots to TOPHR, the final approach fix. This instruction was acknowledged by the PIC.

At 1346:21, flight 183 was instructed to maintain 2,300 feet until established on the localizer, and cleared for the ILS runway 07 approach. The flight was again instructed to maintain 180 knots to TOPHR. This was acknowledged by the PIC.

At 1348:51, the arrival controller transmitted, "grand air one eighty three, contact tower."

At 1348:54, the PIC transmitted, "tower, grand air one eight three."

No further transmissions were received from the airplane, and radar contact was lost.

A witness driving south on a road, adjacent to the west side of Oak Openings Preserve Park, reported that she saw the airplane on final approach. She described it as lower than normal, and north of the final approach course. She stopped her vehicle, stepped out, and watched the airplane fly overhead. She reported that she could hear a popping noise as the airplane passed overhead. As the airplane disappeared from view, she thought she heard a power reduction from the engines. She then got into her vehicle and did not see or hear anything else.

A second witness who was located north of the localizer approach course reported that the tops of the trees, which were 80 to 100 feet high, were obscured by fog. He could hear the engines running intermittently, interspaced with "bangs."

A third witness reported hearing a noise, which she described as, "like a huge drum of nuts and bolts, and you shook it. It was very, very loud and then silence."

A ground search was initiated, and the airplane was located about 1415.

The accident occurred during the hours of daylight at 41 degrees, 34.371 minutes north latitude, and 83 degrees, 51.815 minutes west longitude.

Personnel information

Pilot-In-Command

The PIC held an airline transport pilot certificate for multi-engine airplanes, and a type rating for the DA-20. He held a commercial pilot certificate with ratings for single engine airplanes, rotorcraft helicopter, and instrument helicopter. He also held a flight instructor certificate with ratings for single and multi-engine, and instrument airplane. He was last issued a first class FAA airman medical certificate with no limitations on April 2, 2003.

According to the company, the PIC's total flight experience was 4,829 hours, with 4,384 hours as PIC. His total DA-20 experience was 1,100 hours including 923 hours as PIC. He had flown 82 hours in the preceding 90 days, and 28 hours in the preceding 30 days.

The PIC also held a mechanic's certificate with airframe and powerplant ratings.

The PIC completed initial training in the DA-20 on April 22, 2000. His last recurrent ground school was completed on May 3, 2002. His last proficiency check in the DA-20 occurred on January 3, 2003.

First Officer

The FO held an airline transport pilot certificate for multi-engine airplanes and a type rating for the EMB-120. He held a commercial pilot certificate with a single engine rating. He also held a flight instructor certificate with a single engine rating. He was last issued a first class FAA airman medical certificate with no limitations on February 27, 2003.

According to the company, the FO's total flight experience was 4,632 hours, including 2,000 hours as PIC, and 7.1 hours in make and model. He had flown 63 hours in the preceding 90 days, and 21 hours in the preceding 30 days.

The FO completed DA-20 ground school on April 2, 2003. Prior to the accident flight, he had received 7.1 hours of dual instruction in the DA-20, all from the PIC. He started flight training on March 13, 2003, and his last instructional flight prior to the accident was on April 2, 2003.

Aircraft information

The type certificate data sheet referred to the airplane as a Fan Jet Falcon. The airplane was originally equipped with two General Electric CF 700-2C engines, and had been upgraded to the CF 700-2D2 engines by service bulletin.

The wings were equipped with trailing edge flaps, and droop leading edges (DLE) on the outboard half of the wings.

The fuel system consisted of two wing tanks, and two rear compartment tanks located aft of the aft pressure bulkhead, and between the engines. The wing tanks held 552 gallons on each side, and the rear compartment tanks held 71 gallons on each side.

The airplane had been converted from passenger carrying to a freighter by removal of the main cabin door, and the interior liner and seats. Entrance to the airplane was through the cargo door, forward of the leading edge of the left wing. There were three methods to exit the airplane. The main cargo door and the sliding left side direct vision window in the cockpit could both be used as an emergency exit. In additio

Aircraft

Registration
N183GA
Reported as
Dassault DA-20
Category
Airplane
Serial number
147
Airframe hours
19,093.7
Engines
General Electric CF-700-2D2, 4,500 lbs thrust, turbo fanGeneral Electric CF-700-2D2, 4,500 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Grand Aire Express, Inc.
Registered owner
Czars Inc
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · February 6, 2003 · 38 hours before
Departed
TVC · Traverse City, MI
Destination
TOL · Swanton, OH
Flight plan
IFR
Airport
TOL · Toledo Express Airport, runway 07, 10,600 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
34
Injuries
Fatal
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
January 3, 2003
Seat
Left
Toxicology
Performed
Flight hours
4,829 total · 1,100 in this make and model · 4,384 as pilot in command · 82 in the last 90 days · 28 in the last 30 days
Role
Co-pilot
Age
37
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
December 18, 2002
Seat
Right
Toxicology
Performed
Flight hours
4,632 total · 16 in this make and model · 2,000 as pilot in command · 63 in the last 90 days · 21 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
300° at 9 knots
Visibility
1 statute miles
Lowest ceiling
300 ft overcast
Temperature
32 °F, dew point 30 °F
Altimeter
30.25 inHg
Observed at
TOL, 3 nm away

Docket · 57

The files NTSB released with the investigation on June 10, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.2 MB in all.

Summaries Of Telephone InterviewsItem 1 · .PDF · 84 KBMap Of Witness LocationsItem 2 · .PDF · 164 KBLetter From Director Of OperationsItem 3 · .PDF · 49 KBNTSB - Radar PlotsItem 4 · .PDF · 408 KBMeteorology 5 - Factual Report of Group ChairmanItem 5 · .PDF · 603 KBMeteorology 5 - Attachment 1Item 6 · .PDF · 124 KBMeteorology 5 - Attachment 2Item 7 · .PDF · 123 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 8 · .PDF · 333 KBMeteorology 5 - Attachment 3Item 9 · .PDF · 68 KBMeteorology 5 - Attachment 4Item 10 · .PDF · 108 KBMeteorology 5 - Attachment 5Item 11 · .PDF · 68 KBPowerplants 8 - Factual Report of Group ChairmanItem 12 · .PDF · 2.1 MBAttachment 1 - Saybolt's Certificate of Analysis for the tests on the fuel sample.Item 13 · .PDF · 63 KBAttachment 2 - Forest Products Laboratory report on the charred fibrous material and woodchips.Item 14 · .PDF · 121 KBPowerplants 8 - Addendum 1Item 15 · .PDF · 195 KBOperations Group Factual ReportItem 16 · .PDF · 115 KBOperations Group List of AttachmentsItem 17 · .PDF · 8 KBOperations Group Attachment 1Item 18 · .PDF · 3.3 MBOperations Group Attachment 1 (Continued)Item 19 · .PDF · 1.1 MBOperations Group Attachment 2Item 20 · .PDF · 66 KBOperations Group Attachment 3Item 21 · .PDF · 69 KBOperations Group Attachment 4Item 22 · .PDF · 79 KBOperations Group Attachment 5Item 23 · .PDF · 123 KBOperations Group Attachment 6Item 24 · .PDF · 425 KBOperations Group Attachment 7Item 25 · .PDF · 69 KBOperations Group Attachment 8Item 26 · .PDF · 84 KBOperations Group Attachment 9Item 27 · .PDF · 60 KBOperations Group Attachment 10Item 28 · .PDF · 92 KBOperations Group Attachment 11Item 29 · .PDF · 234 KBOperations Group Attachment 12Item 30 · .PDF · 209 KBOperations Group Attachment 13Item 31 · .PDF · 85 KBOperations Group Attachment 14Item 32 · .PDF · 839 KBOperations Group Attachment 15Item 33 · .PDF · 147 KBOperations Group Attachment 16Item 34 · .PDF · 182 KBOperations Group Attachment 17Item 35 · .PDF · 63 KBOperations Group Attachment 18Item 36 · .PDF · 105 KBOperations Group Attachment 19Item 37 · .PDF · 86 KBOperations Group Attachment 20Item 38 · .PDF · 468 KBMaterials Laboratory Factual Report 04-28Item 39 · .PDF · 374 KBToledo METARSItem 40 · .PDF · 79 KBToledo Approach ChartsItem 41 · .PDF · 104 KBEmail From Dassault AviationItem 42 · .PDF · 64 KBAnnunciator Panel LayoutItem 43 · .PDF · 17 KBRecord Of Last RefuelingItem 44 · .PDF · 134 KBRight side view of airplaneItem 45 · .PDF · 379 KBLeft side view of airplane, broken trees are visible in backgroundItem 46 · .PDF · 452 KBCockpitItem 47 · .PDF · 459 KBAnnunciator panel and surrounding instrumentsItem 48 · .PDF · 367 KBCockpit door - closedItem 49 · .PDF · 194 KBDroop Leading Edge - ExtendedItem 50 · .PDF · 162 KBDroop Leading Edge - RetractedItem 51 · .PDF · 155 KBFAA - ATC Controller StatementsItem 52 · .PDF · 405 KBFAA - Event ReconstructionItem 53 · .PDF · 442 KBFAA - Flight Inspection ReportItem 54 · .PDF · 432 KBFAA - Toxicology Reports (3)Item 55 · .PDF · 167 KBNTSB Parties to InvestigationItem 56 · .PDF · 84 KBWreckage ReleasesItem 57 · .PDF · 162 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.